Expert Commentary

Dr. Ian R. McNicholl discusses the benefits of medication reconcillation and offers a list of best practices for primary care providers in managing that task.

Polypharmacy is estimated to occur in 20-50% of HIV-infected patients, with adverse drug reactions being more common and serious among older patients.(1, 2)

Patients in the Positive Health Program at San Francisco General Hospital currently are taking an average of 9 medications.

Because HIV-infected patients often take numerous medications to treat HIV as well as comorbidities, we expose them to a relatively high likelihood of adverse drug events and drug-drug interactions unless we take steps to proactively manage their risk. Medication reconciliation (establishing a comprehensive, accurate medication list by using information from all sources about a patient's medications, including dosage, route, and frequency) can be a key factor in identifying and avoiding adverse events, drug-drug interactions, and unnecessary or redundant medications.

Medication reconcilation ... should be as much a component of our clinical practice as physical examinations and laboratory procedures.

Given this, why we don't value medication reconciliation more? Too frequently, med reconciliation is viewed as tedious, onerous, and time consuming. But, to manage and protect our patients appropriately, medication reconciliation must be given serious attention and action on our part; it should be as much a component of our clinical practice as physical examinations and laboratory procedures.

Making the Case for Med Reconciliation

Patients frequently buy and use over-the-counter (OTC) medicines, herbal supplements, ethnically or culturally specific remedies, nutritional supplements, and medications obtained on the Internet. Additionally, they may see other providers who prescribe them medications, or may be admitted to a hospital and discharged on new or different medications. Some of these medications, including OTC products, may interact with antiretrovirals.

Performing Med Reconciliation

In my opinion, medication review and reconciliation, and screening for toxicity and drug interactions, are best facilitated by a clinically trained pharmacist, but primary care providers (PCPs) also must be adept at those tasks. My suggestions on how they can achieve that are as follows:

Ask each patient to bring in all medications, including prescribed medications, OTCs, herbals, and nutritional supplements. At least annually, call the patient's pharmacy and have a current medication list and dispensing history faxed to you. That way, not only do you get to see the patient's medications and verify that they are correct (and consistent with your medication list), but you can also document the prescriber, verify the "Sig," check the dispensing history (as an indicator of adherence), and screen for drug interactions.

Request that the patient use one pharmacy, or a pharmacy chain with an integrated computer network. This will make it easier to monitor the complete list of medications.

Consider recommending that your patients use a specialty pharmacy. Use of a pharmacy staffed by personnel with HIV expertise has been shown to improve HIV care in terms of fewer contraindicated medications and improved adherence.(3)

Document the pharmacy name and phone number in the patients' charts (not only for your benefit but also for the benefit of other providers).

Ask patients what other providers they are seeing (eg, cardiologists, psychiatrists, anticoagulation clinic specialists) and document those names and their phone numbers in the charts.

At every visit, reassess the clinical need and indication for every medication.

Beware of "legacy" medications. When patients change providers, their new providers often "continue" all previous medications without adequate assessment and documentation of clinical need. Don't assume that a medication is still clinically indicated!

If a medication is no longer clinically indicated, discontinue the medication in the chart and notify the pharmacy. Simply discontinuing a medication in the patient's chart does not mean it has been discontinued at the dispensing pharmacy! You must communicate with the pharmacy or the patient may continue to receive the medication. And don't rely on simply telling the patient to stop taking a medication; this method is unreliable.

If you're unable to take these actions, or need some assistance, a clinic-based pharmacist may be able to help you.